Results of Antiemetic Management in Terminal Illness

Abstract

A wide variety of causes may be responsible for nausea and vomiting in terminal illness. The different emetic stimuli reach the vomiting centre by a variety of pathways and can be blocked by specific antiemetics that act at the neurotransmitter receptor sites in these pathways. A knowledge of the neurotransmitter receptor antagonist potency of the different antiemetics allows the choice of the most appropriate antiemetic for the relief of the nausea and vomiting caused by a particular emetic stimulus. To demonstrate the efficacy of this approach to the management of nausea and vomiting in terminal illness, the outcome of antiemetic choice in 100 consecutive episodes is recorded.

Systematic review of the efficacy of antiemetics in the treatment of nausea in patients with far-advanced cancer

“…Alternatively, an empirical approach can be followed, trialling various antiemetics without regard to the underlying cause of the nausea. The two prospective audits of current practice [8,10] suggest the mechanistic approach is effective. The empirical approach may also be highly effective [18,19,21,27] however, and the two approaches have not been directly compared.…”

“…The empirical approach may also be highly effective [18,19,21,27] however, and the two approaches have not been directly compared. If a mechanistic approach is to be followed, it is unclear whether an accompanying algorithm for prescribing is needed [8] or not [10]; either way, 80-90% of nausea responds to treatment. Empirical use of antiemetics acting on multiple receptors, such as methotrimeprazine, olanzepine and levosulpride may be as effective as more specific agents selected by the mechanistic approach, but research on this possibility is needed.…”

“…The current mechanistic approach to the management of nausea in advanced cancer which is based on the neuropharmacology of the putative "emetic pathway" should be the basis for choosing first-line antiemetic drugs (grade of recommendation: B [8,10] [8,9,17,37]). 5.…”

“…Experts in the field claim that the cause of nausea and vomiting can be determined clinically in 90% cases [8,9], although they recognize that the cause is usually multifactorial. It is claimed that more than 80% of patients can have their nausea and vomiting controlled when treated in this way [8,10]. The evidence upon which this claim is made warrants review.…”

Psychopharmacology in supportive care of cancer: a review for the clinician

“…However, they still remain useful in the treatment of nausea and vomiting, which is observed in 40-98% of patients with advanced or terminal cancer [19,31,39,61,72]. Again, prior to treatment a careful evaluation should possibly enable the clinician to establish the origin of these symptoms and to identify the pathway of the vomiting reflex and the neurotransmitter receptors involved [52,53,85]. The antiemetic of choice has to be the most potent antagonist to the receptor identified, since its binding affinity predicts the antiemetic efficacy [45,67] (see Fig.…”